Examination

Ankle Examination

  • If a mechanism or pattern:
    • When did it happen?
    • What happened exactly?  Try to understand the mechanism and forces involved (if present)
      • What position was the foot in?
      • Did the foot / ankle move with respect to the body or was the foot fixed and the body moved over the ankle?
    • What symptoms initially?
      • Where were the symptoms initially?
      • Describe pain – sharp / superficial / deep / ache / burning etc
      • What aggravates and what eases?
      • Were and are they able to weightbear?
    • What symptoms now?
      • Have the symptoms changed? Better / Worse? Location?
  • If no mechanism
    • How long has it been there?
    • Is there anything that they believe may have contributed to the development of the problem? Recent activity / inactivity
    • What symptoms are present?
    • Are they there all the time?
  • What treatment has been sought so far?
    • Assessment
    • Investigations
      • If imaging, do they have it with them?
      • If not, can we view it?
        • Private providers use online applications
        • If in another public hospital in Victoria, then can use the “Synapse Mix” service to get the images temporarily put on local network diagnostic imaging servers.
  • What management has been undertaken? Has it been effective
    • Splinting
    • Ice
    • Medications
  • History of problems in that area before
    • When?
    • How was it managed?
      • Assessment undertaken?
      • Investigations
      • Medications
    • Any ongoing problems?
  • Any associated symptoms (if a non mechanical cause or if at all suspicious)
    • Recent illness / fevers / sweats
    • Recent overseas / long haul travel / immobilisation (eg for suspected DVT)
    • Loss of appetite / loss of weight, etc
  • If has a wound
    • Tetanus status
  • If potentially needing procedural sedation or surgery (and consider this for anyone you are contemplating an x-ray for)
    • Fasting status (and tell them not to eat and drink until you tell them it is ok to do so
Distal NV function
  • Color, Movement, Warmth, Sensatio
  • Posterior tibial and dorsalis pedis pulses
  • Common Peroneal / Superficial Peroneal / Tibial nerve function
Active Range of Motion
  • Dorsiflexion
  • Plantarflexion
  • Inversion
  • Eversion
  • Toe movement
Palpation
  • Bony
    • Palpate Fibula and Tibia from knee down to ankle
    • Palpate rest of foot, with special interest in the 5th MT proximally, navicular
  • Ligaments
    • Anterior Talofibular Ligament / Calcaneofibular Ligament, Posterior Talofibular Ligament
    • Anterior Inferior Tibiofibular Ligament
    • Deltoid ligament
  • Tendons
    • Peroneus Brevis
    • Achilles tendon
Special Tests
  • Resisted eversion
  • Talar Tilt
  • Anterior Drawer Test
  • Thompson / Simmonds Test (if suspicious of calf / Achilles injury)
Imaging
  • X-ray
    • Ottawa Ankle Rule (for acute ankle and midfoot pain only)
      • An Ankle X-ray is ONLY needed if the patient has pain in the malleolar zone AND has ANY of the following:
        • Tenderness to the POSTERIOR aspect of the distal 6cm of the fibular OR tibia
        • Inability to weightbear for 4 steps (regardless of limp) BOTH at the time of the injury AND on assessment
      • A Foot X-ray is ONLY needed if the patient has pain in the midfoot zone AND has ANY of the following:
        • Tenderness to the navicular or fifth metatarsal base
        • Inability to weightbear for 4 steps (regardless of limp) BOTH at the time of the injury AND on assessment
    • If has forefoot or toe pain, may still need foot x-ray (not covered by Ottawa Rule)
  • Ultrasound
    • For ambiguous Achilles tendon ruptures or if Orthopaedics have requested
    • If suspicious of peroneal avulsion (no eversion power with pain around 5th MT base and no #)

Ligament Stability Tests

Anterior Drawer Test

Technique

  • Ankle plantarflexed approximately 20-30 degrees and stabilise the shin
  • Either by holding on to the talus from the anterior aspect (which can be quite painful in an acute injury, but extremely useful in assessing long term stability) or via the calcaneus posteriorly, draw the talus/calcaneus anteriorly
 

Interpretation

  • Increased anterior translation and loss of normal endfeel may indicate more significant damage to the anterior talofibular and calcaneofibular ligaments

Talar Tilt Test – Inversion

Technique

  • With the ankle in plantarflexion (stresses ATFL more), plantargrade (CFL) or dorsiflexion (PTFL), “tilt” the talus by applying an inversion type force
  • Assess for pain and laxity
 

Interpretation

  • Laxity on testing dictates grade:
    • Grade I sprain = pain without laxity
    • Grade II sprain= pain with mild laxity
    • Grade III sprain =significant laxity +/- pain

Talar Tilt Test – Eversion

Technique

  • With the ankle in plantarflexion, plantargrade or dorsiflexion, “tilt” the talus by applying an eversion type force
  • Assess for pain and laxity
 

Interpretation

  • Laxity on testing dictates grade:
    • Grade I sprain = pain without laxity
    • Grade II sprain= pain with mild laxity
    • Grade III sprain =significant laxity +/- pain

Tibiofibular Joint Stress Tests

Technique

  • Attempt to sublux the fibular head and lateral malleolus anteriorly or posteriorly.
  • This can be performed in supine or sidelying (which is easier for the patient to relax)
 
 

Interpretation

  • If increased movement, pain with assessment or subluxation is possible, this indicates laxity at this joint.

Muscle Integrity

Thompson / Simmond’s Test
Technique

  • Have the patient in prone, or kneeling on a chair, with their foot off the edge of the bed
  • Squeeze the calf and observe the achilles tendon / foot
 

Interpretation

  • If the foot does not move significantly (compare to the other side), this may indicate achilles tendon rupture
  • Use in conjunction with passive dorsiflexion, resisted plantarflexion and palpation to accurately diagnose potential ruptures.

Supination Force Tests

Jack’s Test
Technique

  • Begin with the patient in standing relaxed
  • Dorsiflex the first toe at the MTP joint until the medial longitudinal arch raises
 

Interpretation

  • Grade the level of resistance to this movement from 1-5 (1 being minimal force required, 5 being significantforce required to dorsiflex the first MTP and raise the medial arch)
  • The greater the resistance to this movement, the more force generation will be required by the foot supinatorsto convert the foot into a rigid lever for push off (and hence greater chance for overload)
  • This test may also be painful for patients with plantar fascia / structure tears or tendinopathy

Manual Supination Resistance Test
Technique

  • Begin with the patient in standing and relaxed
  • By using two fingers adjacent to the tuberosity of navicular, attempt to supinate the foot and raise the medial arch (ensure that the patient does not assist)
 

Interpretation

  • The force is rated from 1 to 5 (1 being minimal force and 5 being significant force required to supinate the foot)
  • Implications are for overuse injuries of the structures which assist to supinate the foot in order to convert it to a rigid lever for push off.

Other Tests

Tinel’s Sign

Technique

  • Repeatedly tap over the tibial nerve where it lies posterior to the medial malleolus
 

Interpretation

  • Reproduction of tingling sensation or pain in the medial foot or heel is suggestive of tarsal tunnel syndrome

Mulder’s Sign

Technique

  • Grasp the forefoot between the fingers and thumb and squeeze
 

Interpretation

  • Reproduction of interdigital pain is suspicious for Morton’s neuroma

Strength Tests

Inversion
Eversion
Dorsiflexion
Plantarflexion

Length Tests

Calf
Achilles